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r�- n•, IED PROGRAM CONSOLIDATED FOIR MW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,17,III,IV,and IX below) 430. ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430x. I DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFd FACILITY ID#(Agency Use Only) `t 1. BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. MCI, dba, Verizon Business BUSINESS SITE ADDRESS 103. CITY 104. 13850 N. DeVries Road Lodi II. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 434. 1 Xerxes ® 1.A STAND-ALONE TANK Complete one page for each ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 1985 550 1 III. TANK USE AND CONTENTS TANK USE ❑ la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ ]c.AVIATION FUELING 439. ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ® 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a. ............6...... ..................................................._.._........................_._.._._............_......_.._.._.........._.........................................................................._...................................................................................................._.._............_........................................ 440. ........................................... .. CONTENTS PETROLEUM: ❑ la.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS El 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 440a. ................................................................................. . . .. M: IL NON-PETROLEU ❑ 7 USED.O ....._......_...................................... ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b. IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. .......................-.............................................................................................-................................................_................._.........._............-........._._.......................... PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444. ❑ 7.STEEL+INTERNAL LINING ..... . .................................................. ....__..._..__._.._.._............... SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445. ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a. ......................._.....................................-............................................................................._..................._..................................._.......-----................................................_................ -....._...__..... _... - OVERFILL PREVENTION ® 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE a52. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 60. ......................_....._...__.._...................._...._..........._.._..........................................._......................................................................................_.._........................_.._.......- -"----... - SYSTEM TYPE ❑ 1.PRESSURE ❑ 2.GRAVITY ® 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)] 458. _..._...................................................................................................................................................................................__.._.............................................._....._.......................__...-........._................ PRIMARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464. _ ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a. _........................................................................................................................................................................................................................_.............................................................................................. ................__........._._..........- SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC 646. ❑ 90.NONE ❑ 95.UNKNOWN C199.OTHER(Specify): 464c. ................................_.._............_......................_..................................._.................................................................................... ..._..........__...........__........_....._. PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644. VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46641. .............................................................................................................................._...........__.._._._........_....._.._...---..._.__.............................................................................._........................................................................................................................._.._......................_._.....__._.............._....................._.... ................ VENT SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS [:110.RIGIDPLASTIC ® 90.NONE (399.OTHER(Specify): 464fl . VR PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464gt..._., .............................................................................................._..._.....__..__...............--'---.........._.....----............._.._..._........._._..............__..._......................_............................................................................................_..._..__._._....._....._........__...-'-------._..__._..................._...................._._. 464h. VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 464hl. ..............._..........................................................................._...........__.....................---....__...._............-_......_._........_....__........_..__..._......................_............_........................................_.............._..............................__............_.._..__.._.._..........._..._..........._........_...._......_.._......_...._.__. ...;_.... VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 464i............. . ..........................................................._..........._....._........__......_...._.............................................._..........................._............. ................. 10 RIGID PLASTIC 90.NONE 99.OTHER(Spec RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS G ❑ O ® O ❑ fy ( P ) A641. RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464k1. .............._..._............................................_........................................................................................................................................................................................................................................._.............I.............................. FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 45la-c. VII. UNDER DISPENSER CONTAINMENT'(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 3.NO DISPENSERS ❑ 90.NONE 469a. ....................................................................................................................................................................._..._.....----........_.__...__................. CONSTRUCTION MATERIAL ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 69c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate,and in full compliance with legal requirements. APPLICANT SIGNATUETK I� '_� DATE 9/3/2009 470 APPLICANT NAME(print) Todd Harris 471 APPLICANT TITLE Regional Environmental Manager 472 UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org